Thoughtful Thursday: Selective

March 18, 2009

Today’s topic is a controversial one; a topic that is extremely relevant to many people dealing with infertility, yet which I’ve barely heard even mentioned in the blogosphere. As you may have noticed, I’m no shrinking violet. I’m not afraid to tackle the topic head-on — even if the thought of actually dealing with it scares me shitless.

Let’s talk about selective reduction.

It’s a topic that I thought a lot about during IUI #5 (my first FSH cycle), then forgot about once I moved on to IVF. Now, after my preposterously high 2nd beta, it’s back on my mind.

I truly don’t know how many gummy bears I’ll see on the ultrasound next Tuesday — hopefully not zero, of course. Maybe it will only be one — that would be fantastic. Two would be fine. More than that and I start to get very worried. Lots more and I freak-the-hell-out. Mostly because of the incredible risks of carrying higher order multiples — prematurity, low birth weight, disabilities, death. With triplets, the odds are almost 50/50 that the pregnancy will be lost entirely or that one or more of the babies will die after birth. With more than triplets, the risk increases even more.

I’ve written before about the reasons why I would choose selective reduction, although I have always desperately hoped that I’d never be faced with that decision and although I know that it would break my heart and haunt me forever.

Of course, prevention is preferable. I would never transfer a large number of embryos in an IVF. Many patients or doctors choose to cancel FSH cycles when there are too many follicles. But, the option of canceling an IUI cycle due to a high number of follicles has never come up for me, because the odds of even one baby sticking have been so low. Cancellation never even occurred to me with this most recent IUI, because it was the cycle that I gave a 0% chance of working and was doing just to meet an insurance requirement.

So, let’s say that without irresponsible actions (for example, transferring 6 embryos after having multiple successful IVFs in the past), you ended up pregnant with higher-order multiples. How many would be enough to make you consider reduction? 2? 3? 4? 5? 6? More? Or would you never consider reduction no matter what, even if the lives of the babies were in jeopardy? What if your life were in jeopardy?

I won’t know my true answer unless/until I’m faced with it. But, I’m pretty sure that 4 would be too many. Maybe 3. DH’s number is definitely 3. He says they’re only “theoretical children” at this point anyway. This decision is much easier for him.

I am hoping so desperately that I won’t actually have to deal with this decision, but I think it’s good to think through preliminary plans while I’m relatively calm. And, since I’ve seen so little on this topic among ALI bloggers, I’m very curious to see what people think.

My number will be *4*. That is, if four embies would have magicalized (new word that!), I would have seriously considered reduction. In my IVF #1, three embies had made their way into my uterus, and I was prepared to have all the three, if they would have taken up.

I remember sitting in the doctor’s lobby and watching a patient whose MIL was deep in conversation with her. I came to know that she was there for a ‘reduction’, and I have wondered till date as to what criterion was chosen to define, who to take out and who to retain.

Think well about it, contemplate on DH’s point of view as well, and the medical advice. I just hope that you do not have to make that painful choice. But I know that life does not make us have any easy paths. Let’s see, what the ultrasound shows.

Selective reduction was mentioned at my first US when we saw 3 sacs, my doc looking at me(small) and my husband (very tall) did not think triplets were a good idea. Thankfully we never had to make a decision as by the next US there were only 2.

My twins were however born extremely premature (25 weeks)and I know if I can convince my husband to have more children (NICU has left him pretty shell shocked) we would only want a singleton. Unfortunately in my case it’s been proven my body can’t handle multiples.

So I guess my answer would be one would be my limit. That being said I truly hope I never have to make that decision.

Good luck for your US next week, I really hope you don’t have to make this difficult decision either.

This is a very good question and one that in the surrogacy community, must be thought about extensively prior to seeking intended parents or surrogates. This topic often leads to extremely heated conversations on Surrogate Mothers Online (SMO), where I am one of the five moderators. I almost always have to intervene when the thread ends up pages and pages long and the hormones are raging.

When I was younger, more fit, and before my second c-section, if a doctor allowed it I would have carried up to three. If it had been my first pregnancy, I would have tried to carry all and not opted for selective reduction.

As a surrogate who has had four prior c-sections, I doubt that any doctor would feel comfortable with me carrying more than twins due to increased risk of uterine rupture. Chance, Apollo, and I have talked about this and should I end up pregnant (*cough*) with more than two (*coughcough*), we will likely choose S/R, which is a thought that does make me terribly sad. Our RE won’t transfer any more than two, so if I did end up pg with triplets, it would definitely be a case of identical triplets so it would likely be a matter of reducing the identicals, thereby losing two babies and not just one. This thought makes a terribly difficult scenario even more difficult to think about.

I’ve seen many surrogates/intended parents faced with the prospect of S/R. Some chose to carry all, some chose to reduce. I’ve seen situations where the two parties were at odds and it ended up being a complete nightmare of a situation. Complete.

I hope that you won’t be faced with this difficult situation and I applaud you for having the cajones to ask about this topic head-on.

This is incredibly difficult and personal. Having not been through any medical interventions to get pregnant, I’m not even sure what the criteria what factors I might need to consider in terms of ensuring viability etc. That said, it took us long enough to get pregnant the first time around and I’m concerned enough about the second go-around to make me think that it would be very hard for me to say no to the possibilities inherent in multiple embryos. Then again, my husband and I once upon a time thought that 4 kids might be the right number for our family. I’m thinking if I were pregnant with 4 simultaneously that might be the place where we draw the line and say, “We really need to think about managing this number…”

It seems like it’s easy to be an armchair quarterback when you’ve never been on the field of play. I don’t see how anyone can tell you what to do either in terms of managing the pregnancy or the babies.

I too am hoping that you don’t have to make that decision. It’s hard to comment on unless you are in or have been in that position so I’m gonna go the safe route and say that I’d have to decide if I was faced with it.

It’s not something I like to think about, especially since the infertility road is not at an end yet and has been so long. I can’t begin to imagine making that decision because I don’t know if I could because I wouldn’t want to take away something I’ve been fighting so hard for but I do also understand the risks. I’m praying that your numbers are just freakishly high and there’s just one or two in there!!

Cassandra, you are so brave to write about this publicly. You’re right, this is a rather taboo subject in the blogosphere. While I have many strong feelings and opinions about this, I’m not sure I’m brave enough to publicly answer your specific questions. I will say that I’m vehemently pro-choice. I’ve never had an abortion, but STRONGLY defend a woman’s right to choose. I feel so strongly, that I have done clinic defense and escorting in the past.

Like you, if I felt I needed to reduce a pregnancy, it would “break my heart and haunt me forever.” I think you are wise to have had these discussions already with your DH. Unlike peanuttam, I think it’s important to not wait until you are faced with the decision. Better to think this through with a clear head, before pregnancy hormones are high and one is confronted with all the ultrasound pictures.

Sweetie, I want you to know that if you are faced with this, my shoulder is yours. You can call me or email me, and I will be there for you without an ounce of judgment. I completely agree with Heather. It’s up to you and your DH as to what’s best for your family. Hoping for a healthy singleton for you.

Honestly, I think my answer to this is sort of a moot point since I would most likely never have to do IUI in the first place (my problem is staying pregnant, not getting pregnant). So it is easy for me to say that I am pretty sure that I would never selectively reduce (though I will definitely say that it is difficult to truly know what you would do until you are actually in the situation, so maybe I would change my mind if I was in the situation myself), but I would also say that for that reason I would probably never do IUI. But again, I recognize that my situation is different and it is easy for me to say that. If my situation was different then it would not be so easy to just rule out IUI as a possibility.

So ultimately, yeah, my response isn’t really helpful to anyone who is actually in that situation. I definitely don’t think there is a “right” answer. I know like another commenter said, my main fear is with my history of m/c, what if I selected and the ones that I left didn’t survive? There is just no way to know.

I hope you don’t actually have to make this kind of decision and that you just have one or two sticky beans in there! (((hugs)))

I think I would have to be pregnant with more than 3 to be able to even think about reduction. I can understand any decision an individual makes but, for me, that would be the point I would have to hit to consider it.

When we thought that IUI might possibly work and had 4 eggs going into the first procedure, we decided ahead of time to reduce if it was more than 3. I had read an article in Esquire of all places that advised discussing all-case scenarios before you started fertility treatments and stick to them, so that’s what we did.

However, I didn’t know the odds against carrying three were so high at the time that we made our decision.

I think this would really depend on whether I planned to work through my pregnancy. I’m a writer/editor, so I could’ve worked from home if put on extreme bedrest. But if my job didn’t allow for me to do that and I couldn’t afford to quit or go w/o the insurance that I get from said job, I would probably reduce down to 2.

Though, as someone who had an abortion in her early 20s, I can say that I’m not haunted by that decision — even knowing what I know now, I still would’ve made it, especially since it wasn’t a factor in our inability to conceive spontaneously.

However, I also know that it’s hard to know now if these decisions will haunt you later in life.

I always favor going with the practical solution in these cases. Ask yourself if you and your finances and your relationship can handle extreme bedrest or having more than one or two children. Try not to overestimate yourself. And make the best decision for you. Babies need a ton of time and attention, but you’ll also need to reserve something for yourself. So making the decision that best suits your lifestyle isn’t selfish. In fact, it basically ensures that you’ll be the best mother that you can be.

Having carried triplets and lost our three sons at just over 5 months, I could never go through that again. My number used to be three (obviously, we were pregnant with three and chose not to reduce). We’ll never put back three embryos again. Two at the most, and even two makes me very, very nervous. G-d forbid one should split and we’d end up with three–I’d have to reduce. Now that I know about the scary world of incompetent cervix issues and premature membrane ruptures and that whole nightmarish scene, I’d never want to put myself or my babies in the very real medical danger that can come with a triplet or higher order multiples pregnancy (frankly, even twins terrify me now!).

That said, I have friends who’ve carried both triplets and twins with very few complications, so I know it can be done. I don’t mean to scare anyone, this is just my personal take on the question giving my experience with carrying and losing three babies.

This is a tough one, and one that I don’t think I can answer right now. It’s just so hard to even fathom being pregnant with one – I can’t even imagine more than that.

I am hoping that this is not a decision you’re going to have to make and that your high beta is just evidence of a very healthy baby. I do appreciate you bringing up the tough stuff, though. It’s what I love about Thoughtful Thursdays.

I feel a bit like the armchair quarterback mentioned above in that DH was so against S/R that we didn’t even have the conversation. I didn’t push it either, though, because a friend just had an eventful yet successful triplet pregnancy (embryo split) and gave birth to three healthy girls in Dec. If one of ours had split and we ended up with four, that’s where I would draw the line and really push for S/R. I just think four is too many to still end up with a health pregnancy and healthy babies. I have high hopes for our triplet pregnancy and have been/will be very, very careful, and am keenly aware that ours is a high risk pregnancy.

I hope you don’t have to make this decision and that you just have a fast-growing baby or something.

Like many others have said, this is something one doesn’t know the answer to unless faced with the decision. However, preliminarily, I’d strongly consider it if need be. I suspect my number to reduce would be 3+. My RE would not let me get to that point anyway; he rarely transfers more than two.

I initially conceived twins with my pregnancy after our IVF. At 10 weeks or so, U/S revealed that baby #2’s heart stopped beating. It still hurts if I let myself think about it for a prolonged period of time. At the same time, I am at peace with it as well. What if my baby is as healthy as he is today because of the loss of baby2? Would baby 2 have been as healthy as baby1? What if baby 2 had been born with devastating medical issues? What if baby1 in all his healthy glory suffered because baby2 required all of my attention? All of this to say, as a healthcare professional, my biggest fear is devastating medical illness and the impact of poor quality of life. All I can say is that I’d weigh all thoughts.

I will second the hope that you do not have to make such a difficult decision.

I’ll start by saying that until reading this I did not know that the odds were so low for triplets. I think that would factor in to my decision. I think that after spending so many years trying to get pregnant and bring home a baby that I would not want to risk a HOM pregnancy. I had been thinking three is the limit but now I am thinking that would be risking too much. I have a 5% (or less) chance of getting pregnant in any given cycle and, if I ever hit the jackpot, I wouldn’t want to put the babies at risk by trying to carry too many. I would educate myself as much as possible so that I felt sure about my decision. I haven’t even talked to my DH about this because it has never really been an issue — I think I was warned about multiples during just one of 9 IUI cycles. (Color me a poor responder.)

We’ll all be rooting for you no matter what happens, no matter what you decide.

Tough one. But we discussed at great length so we could say we’d had rational discussion in case we should ever find ourselves in that emotional place. We agreed we’d try to carry 3 but if there was evidence at the time of decision that any of the babies or I were at risk we’d reduce to 2. Not pretty. Not proud of it. But – we have never had to look that decision in the eye…

I am hoping you won’t be faced with this question either. I’ve never really thought much of it during the 10+ years of IF treatments, as it’s so hard for me to become pregnant with one that I haven’t thought I could end up with too many. I do have a good friend at work, though that has two 3 year old boys and she did have an S/R done when she was pregnant with them. She was pregnant with four and she’s such a petite little thing (5’1″) that even carrying twins was difficult. I don’t think she regrets her decision at all.

Tough to answer since the possibility of having to make this decision seems so theoretical and out of reach for me right now! Not something DH and I have ever talked about, but I am sure we would be on the same page. Working in a children’s hospital, I see the potentially devastating, life-altering risks of multiples every day. I think this skews my decision—I don’t see the healthy twins and triplets that may have been born close to term & sent home with the parents. Though I try to think “rationally” my experience & comfort zone often shapes my decisions more than facts & figures; I know friends & colleagues with healthy twins, but no more, so I would think very hard about S/R if I were having more than 2, and definitely more than 3.

I imagine that there is no right answer for anyone which in itself is so heartbreaking. What I can say is that I carried and had/have twins and I could not have done more. For me this was risky enough and even now as toddlers I thank my lucky stars that I didn’t have more than 2. But that’s me and I didn’t have to suffer all the heartbreak that you have to reach this point.

Do you think it may help to list the pro’s & cons in a sort of ‘clinical’ fashion? I’m not sure if it would be perhaps seeing the list would provide a little bit of comfort should you need to choose a number?

I do remember that my 2nd beta exceeded 6000 so there is a good chance that it is 2? 🙂

I don’t feel squeamish though when I hear or read about S/R. In a manner of speaking its a chance to give a baby or two the best chance at live and a healthy life at that. But if I were in the shoes…. I would be devastated at having to choose. After all my miscarriages it would be a cruel joke for me to be pregnant with high order multiples and they were ALL doing well… how could you choose in that sitch? You just couldn’t. I’m one of those emotional wrecks that mourns a bunch of first trimester cells as a baby and sometimes I wonder about the sex of the babies etc… I can’t imagine having to live with myself at the thought of S/R a healthy heartbeating little peanut shape. Pointing at it on the ultrasound and going “that one”. (or asking the doctor to choose, or whatever).

BUT… the thought of carrying any more than 2 is terrifying to me. More than 50% of moms that were in the infant loss support group had twins or triplets. Prematurity is a HUGE issue. IC. PROM. So is intra-uterine growth.

I’m glad to say I won’t have to face the option because hell would freeze over before my specialist would transfer more than 2 to my needy uterus. I wouldn’t S/R unless I had 4 or more. But even trying to imagine that would be hard. The battle of ‘instant family’ vs ‘4 more dead babies’… not easy, so personal and painful.

I really, really want this pregnancy of yours to be uncomplicated, simple, boring even… (medically speaking) so I hope in the name of fuck that you don’t ever have to make the choice.

In the infertility world, one is truly the best number. So many healthy twins or triplets or quads out there. There is hope. But everyone is different. That’s what’s scary.

I am so impressed by the thoughtful comments! I hope you do not have to face this, but I guess each of us on the ART journey kinda needs to think about what if– even if it is a long off crazy odds kind of thing– for my doc, we talked about it before we talked about which treatment- with the doc, with the psychiatrist, again with the maternal and fetal medicine guy. But I also learned that there is not much selective about selective reduction- they reach what they can, so it is not as exact a science as I wish it were (but then, how would you/they decide which one or ones? what other criteria would make sense?)

So I knew that more than 3 is crazy for a body to handle and for the safety and health of all of the little ones and since I was really hoping for a positive outcome that was my number– But that does not mean there is anything easy about this sort of decision. For me (with advanced maternal age)–even 3 is crazy.
Of course, one seems to be impossible, so this may most likely be moot. Good luck with everything, and I am hoping for the best possible scenario for you– one precocious one, or two– and that’s it.

I believe that no woman should be forced to have more children than she wants or feels able to handle at one time. Any number of multiples is difficult on the body, your relationship with your husband, and the children. The thing I really hate the most about fertility treatments is having to grapple with these very difficult decisions. I wish the technology was a lot more precise. Wishing the best for you on Tuesday!

I just don’t want to be Kate. Hell I can’t even afford to be Kate. I would probably let nature take its course, only because I couldn’t bring myself to have gone all that way with infertility, and then possibly put the whole thing in jeopardy because I was too successful? Sounds weird to think like that after being good at failure for so long. ICLW

Hard decisions. I transferred 4 embryos and got 1 baby. But the risk of HOM was lower for me due to many other issues with my lining and my age being a factor. But if for some reason I got all 4, that would be too many.

I just can’t answer. Let’s just say that I would cancel an IUI if I had more than 2 follicles – IF I had perfect lining, perfect pregnancy indicators, etc. It’s just hard for us who have other circumstances like so many failed IUIs and IVFs. I don’t know how many follicles you had, but due to your IF record, I don’t consider you irresponsible to go ahead with the converted IUI even if you had more than 2, which I’m sure you did. But I AM totally against the young girl I know who over stimmed on an IUI and doc cancelled her IUI and she went ahead, triggered and had intercourse, giving her 9 heartbeats where she reduced 7 of them. To me, I figure she killed those 7 babies because of her selfishness. But for you, if for some reason you ended up with 9 heartbeats, I would totally understand. I mean, both of the situations would need selective reduction but her I’m pissed at. You – it would just be more “bad luck” you’d have to deal with.

I guess to answer, I would say 2 is the safest number of multiples. But if I had 3 heartbeats, would I reduce to 2? Probably not. But if I had 4, 5, 6, etc, I would reduce to 2.

I hope you find 2 beautiful heartbeats at your appointment. My own heart is with you and your situation.

1. I am still trying to get over your number — that is mindboggling! I don’t know whether to congratulate you or not — I will say I hope this is a smooth pregnancy that results in beautiful, healthy bab(ies).

2. After trying so hard for nearly seven years and not once having a BFP, I honestly don’t think I would have the heart to reduce. That being said, I’ve never had more than 2 follies on any of our stimulated cycles, and we have VERY low morphology, so the chances of HOM is low. We are getting ready to move onto IVF, though, so I know that this discussion will have to take place. I just can’t imagine trying to hard to get PG and then being faced with such a difficult, heartwrenching decision. It just doesn’t seem fair.

3. I cannot BELIEVE the person mentioned in the above comment. 9 heartbeats? WITHOUT an IUI/IVF????? Talk about boggling the mind.

I don’t know what the right answer is, but it a question that needs to be answered at some point by all of us I think. I’m not currently looking at IUI or IVF, but it’s something I know I will have to answer for myself when and if we get to the point of IVF. In theory, I wouldn’t do selective reduction. But faced with the situation, I really don’t know.

I think 3 would be my number. I had to consider this briefly as a possibility when my RE’s office almost made me cancel my cycle due to too many follicles (7). We went ahead with timed intercourse anyways and that’s when I started to look into reduction. 3 was the number I decided on. Thankfully, we had one sticky bean who is growing well at 25 weeks now. I am ever so grateful that I took the chance and lucked out by not having to make the choice.

Wow, this is a tough one (as, I realize, everyone has already mentioned!). I am scared of carrying even 2 given the associated risks with even that number. I think 3 would be my likely maximum, depending on doctor advice, etc. I feel that I am of course making this hypothetical choice without a lot of the information I would need, but as an uninformed party, I can’t imagine how hard and heartbreaking this decision must be. I’m hoping you are not faced with it!

Good topic! I really have no idea since I don’t know what the stats on HOM are, but once the risks outweighed the benefits we would definitely consider selective reduction I think. Maybe 4? I don’t know…

This IS a thoughtful post. I really hope you don’t have to actually practice what you are thinking about, though. And congrats again on the pregnancy!

I have thought a lot about this topic because I am someone who transferred 6 embies at the same time. Granted, they all weren’t the best quality, but still. We’ve all heard of those little engines that did when everyone thought they wouldn’t. So, even though I never expected that many to implant, my plan was to reduce to three if I had to–as early as possible as sort of I won’t have time to get too attached plan. (not that the not getting too attached part of the plan would have worked or anything)That being said, I was pregnant with twins and found out that my body wouldn’t have done too well with trips as I delivered at 28 weeks.

Oh, I’m still so happy for your bfp but TOTALLY understand your caution with your number. A good friend of mine just discovered she was pregnant with FOUR after a 3 embie IVF cycle. Yes! One split. Two babies are very healthy and two are behind, so they may not make it.

I had pre-term labor with my son at 24 weeks and spent the entire rest of my pregnancy on bedrest before having him at 36 weeks. So one is the magic number for me. My doctor will cancel any cycle with three of more mature follies. It’s just to risky for us.

Wow, I had never considered this. You know what, I don’t know what I’d do. I guess if I knew that my health/life would be at risk as well as my babies, I would choose to reduce. But putting a number on it, I cannot even fathom that now. I hope this is not a decision you are faced with. I sure can’t wait to hear about your ultrasound tomorrow. xoxoxoxo

First of all, congratulations on the surprising BFP on the perfunctory IUI.

Anyhow, I would like 3 max. I would be more on the preventive/proactive side and just transfer maybe 4. Then stick my head on the sand until it is beta/sono time to find out if they took and how many took.

BTW, I was trying to look for a post that mentioned how many follicles you had – is that anywhere here?

it’s such a hard decision, but i think it’s important to think about these things ahead of time. i’m teetering between two and three myself, but i think i’m leaning towards two. hopefully i’ll never have to make that decision, but if the time ever comes, at least i’ll be semi-prepared (well, as prepared as someone can be in a situation like that).
iclw

My husband and I are on different pages with respect to S/R. He would want to reduce if there were more than two. I am really opposed to S/R – for me, not in general. When we were deciding how many to transfer on the current (DE) cycle, my husband said “no more than 2 because I know you won’t reduce.”

But even I have to admit that once you get to 4 you will have to start thinking about it very seriously, because with 4 you have to expect that, on average, at least 1 will die or have a very serious disability. If we had 4, we would have a huge fight about reduction, and I don’t know how it would come out. If we had 5 or more, it would be a sad but necessary thing to do.